Limb spasticity and telemedicine consultation for reconstructive surgery: patient perspectives of surgical assessment.

CONTEXT: Spasticity is characterized by increased muscle tone and stretch reflexes, often caused by an upper motor neuron (UMN) syndrome. Many patients live with their dysfunction of their upper or lower limbs for many years and are managed by a multidisciplinary team including physical medicine and rehabilitation specialists, neurologists, and/or physical therapists in an attempt to decrease their spasticity and enhance their quality of life. Reconstructive surgery is a treatment option for many patients living with spasticity. The goal of surgery is to permanently decrease their spastic tone and improve their quality of life. Spastic hemiplegia or hemiparesis is an area of orthopedic surgery that is uniquely suited to telemedicine evaluation. Telemedicine visits can lower the threshold for patients to obtain consultation, receive second opinions, and determine whether traveling for an in-person assessment might be worthwhile, particular to larger medical centers. OBJECTIVES: The objective of our study was to characterize patient perceptions of telemedicine consultation for spasticity surgery and to determine its effectiveness for indicating reconstructive procedures. METHODS: An electronic survey consisting of 16 questions was distributed to all patients after the virtual consultation from April 2020 to September 2022 as part of a neuro-orthopedic evaluation. Domains of inquiry included patient demographic and diagnosis information, satisfaction with provider assessment, ease of use, appointment preference, and whether surgery was eventually performed. Identifying information was voluntarily provided by patients and allowed for survey data to be linked to the medical record. Patients were included in the study if they were diagnosed with upper and/or lower extremity spasticity, were evaluated by telemedicine visit, and were over the age of 18. They were excluded from the study if they were evaluated for any condition aside from spasticity or returned an incomplete survey. Patients who completed the survey were prospectively followed through December 2022 to determine whether a subsequent in-person visit was pursued and/or reconstructive surgery was performed. RESULTS: A total of 19 of 36 patients completed surveys, for a response rate of 52.7 %. Nearly all (94.7 %, n=18) patients felt that the provider expressed maximal concern for patient questions/worries, included them in decisions regarding care, and appropriately discussed treatment strategies. Similarly, the majority (89.5 %, n=17) were maximally satisfied with explanations about their condition and would recommend the care provider to others. Most patients (84.2 %, n=16) also felt that the ease of communication via the virtual platform was very good. All patients were eventually indicated for and subsequently underwent reconstructive surgery for spasticity. CONCLUSIONS: Spasticity patients were overwhelmingly satisfied with their initial virtual consultation as an alternative to face-to-face visits. Telemedicine provides a clinical opportunity for seeking information about spasticity surgery and offers a cost-effective and convenient option for patients who find travel to specialty centers prohibitive.

Optimal hand surgery fellowship interview format.

CONTEXT: The ideal format for residency and fellowship interviews has been consistently debated. Secondary to the COVID-19 pandemic, many institutions, including all hand surgery fellowship programs, transitioned interviews to an all-virtual format. In the past year, with ease of travel restrictions, some programs have transitioned back to in-person interviews, while others remain solely virtual. Hand surgery fellowship programs are continually assessing what are the best means for conducting these interviews, with little perspective regarding the applicant's preferences. OBJECTIVES: The purpose of this study was to examine hand surgery fellowship applicants' perspectives regarding in-person and virtual interviews. It was hypothesized that applicants would value interpersonal relationships between faculty when deciding upon their ideal hand surgery fellowship, which would be easier to appreciate in-person. METHODS: All hand fellowship interviewees at a single institution were given a voluntary, electronic survey. The survey consisted of questions examining different aspects of the program's interview day and supplemental resources. Responses were recorded after the in-person interview for the years 2018-2020. Questions were altered for the virtual 2021 and 2022 interviews. Questions were scored on a Likert scale. RESULTS: For the in-person interview cycles, there were 60/86 respondents (69.8 %). For the virtual interview cycles, there were 45/73 respondents (61.6 %). During the in-person interview cycles, applicants reported that the current fellows' perspective talk was the most helpful component. Many applicants commented that they enjoyed meeting their potential co-fellows. The virtual interviewees felt that they had the best understanding of the program's core values/culture and the worst understanding of faculty personalities and personal/family life. Twenty-nine (64.4 %) of virtual applicants would prefer an all in-person interview. Of the 16 respondents who did not advocate for a completely in-person interview, 56.3 % preferred the option for an in-person site visit. CONCLUSIONS: Hand surgery fellowship applicants desire interpersonal interactions to better understand prospective fellowship programs, which can be difficult to convey with an all-virtual interview. The results of this survey can help guide fellowship programs as they continue to optimize in-person, virtual, and hybrid interview formats and refine recruitment resources.

Assessment of 30-Day Adverse Events in Single-Event, Multilevel Upper Extremity Surgery in Adult Patients with Upper Motor Neuron Syndrome.

BACKGROUND: Upper motor neuron (UMN) syndrome consists of muscle spasticity, weakness, and dyssynergy due to a brain or spinal cord injury. The purpose of this study is to describe the perioperative adverse events for adult patients undergoing single-event, multilevel upper extremity surgery (SEMLS) due to UMN syndrome. METHODS: A retrospective case series was performed for 12 consecutive adult patients who underwent SEMLS to correct upper extremity dysfunction or deformity secondary to UMN syndrome. The evaluation consisted of primary outcome measures to identify readmission rates and classify adverse events that occurred within 30 days after surgery. RESULTS: All 12 patients were functionally dependent with 50% (n = 6) men and 50% (n = 6) women at a mean age of 43.6 years (range: 21-73) with a mean of 5.92 (range: 0-16) comorbid diagnoses at the time of surgery. There were no intraoperative complications, hospital readmissions, or deaths among the 12 patients. Five patients experienced 5 minor postoperative complications that consisted of cast- or orthosis-related skin breakdown remote from the incision (n = 3), incidental surgical site hematoma that required no surveillance or intervention (n = 1), and contact dermatitis attributed to the surgical dressing that resolved with topical corticosteroids (n = 1). CONCLUSIONS: With an appropriate multidisciplinary approach, there is minimal risk for developing perioperative and 30-day postoperative adverse events for adults undergoing SEMLS to correct upper extremity deformities secondary to UMN syndrome. LEVEL OF EVIDENCE: Level IV.

Cost Savings and Patient Experiences of a Clinic-Based, Wide-Awake Hand Surgery Program at a Military Medical Center: A Critical Analysis of the First 100 Procedures.

PURPOSE: Wide-awake, local anesthesia, no tourniquet (WALANT) hand surgery was developed to improve access to hand surgery care while optimizing medical resources. Hand surgery in the clinic setting may result in substantial cost savings for the United States Military Health Care System (MHS) and provide a safe alternative to performing similar procedures in the operating room. METHODS: A prospective cohort study was performed on the first 100 consecutive clinic-based WALANT hand surgery procedures performed at a military medical center from January 2014 to September 2015 by a single hand surgeon. Cost savings analysis was performed by using the Medical Expense and Performance Reporting System, the standard cost accounting system for the MHS, to compare procedures performed in the clinic versus the operating room during the study period. A study specific questionnaire was obtained for 66 procedures to evaluate the patient's experience. RESULTS: For carpal tunnel release (n = 34) and A1 pulley release (n = 33), there were 85% and 70% cost savings by having the procedures performed in clinic under WALANT compared with the main operating room, respectively. During the study period, carpal tunnel release, A1 pulley release, and de Quervain release performed in the clinic instead of the operating room amounted to $393,100 in cost savings for the MHS. There were no adverse events during the WALANT procedure. CONCLUSIONS: A clinic-based WALANT hand surgery program at a military medical center results in considerable cost savings for the MHS. TYPE OF STUDY/LEVEL OF EVIDENCE: Economic/Decision Analysis IV.